Eye on Ethics

Eye on Ethics: How R U Doing 2day? Social Work in a Digital Era
By Frederic G. Reamer, PhD
May 2015

Several months ago I received a call from a reporter for a national publication who asked me what I thought about what she described as a new therapeutic service whereby therapists and clients communicate solely by text messaging. "Run that by me again, please," I said. "Do you mean e-mail exchanges and online chat between clinicians and clients?" "No," the reporter said. "Text messaging. That's it."

I explored the new service's website and, lo and behold, the service offers unlimited text message counseling via an app that users download on their smartphones. Users are linked with licensed clinicians who agree to respond to their messages once daily.

Since that interview, I have shared information about this novel clinical service with various groups of social workers at a number of professional conferences throughout the United States and abroad. I share this website option as an example of the ways in which digital technology is changing the nature of social work practice and ethical standards. Typically, I ask audiences to share their thoughts about this therapy-by-text service; I try my best not to "lead" the audiences one way or the other, pro or con.

To date, the vast majority of the social workers I query—most of whom are clinicians—have shared their skepticism about the ability of this kind of text-based service to substitute for traditional, face-to-face social work counseling. Most critics comment on likely problems when clinician and client are not in each other's physical presence. Without visual contact, many say, a clinical social worker would not be able to see and respond to a client's clinically relevant facial expressions and body language, including smiles, winces, tears, and squirms. Clients would also not have access to their social worker's visual cues, which may also be important.

Clients with very serious mental health challenges and risks may not get the in-depth and sustained help they need, which would be more available in the context of more traditional face-to-face clinical relationships. Also, clients who depend entirely on text messaging for mental health services may be at risk when they encounter crises and emergencies. Clinicians who are located far from the client's community may have difficulty in directing clients to emergency services, beyond encouraging them to call 911. 

Text messages are also susceptible to misunderstanding and miscommunication. All of us, I suspect, have discovered on occasion that after we tap "send" on our smartphones, our text message contains misspelled words or expressions that can lead to confusion, especially when we dictate our messages for conversion to text. 

It is also possible, even if not likely, that text message therapy would compromise clients' and social workers' privacy and confidentiality. Once social workers send messages, which may contain sensitive information, to clients, the social workers may not be able to control whether clients forward these messages to a third party without the social workers' knowledge or consent. 

Further, social workers who provide digital services that cross jurisdictional lines may not realize that the jurisdiction in which the client resides may require the social worker to be licensed in that jurisdiction. Increasing numbers of licensing and regulatory bodies are adopting regulations that require providers of distance and digital services to be licensed in the client's home jurisdiction, regardless of where the practitioner practices. 

Possible Advantages
But even the most ardent critics and skeptics recognize there may be some advantages to distance counseling. They acknowledge that distance and digital services can provide assistance to people who might not otherwise get help, perhaps because they live far from mental health service providers, are seriously disabled, or are well known in their local communities and prefer the privacy protections afforded by distance and remote services. Also, some clients report that they are more candid and open with social workers when they communicate with them digitally. For some, apparently, this is a "safer" way to get help.

In addition, distance social work services may be much more convenient for some clients than traditional face-to-face services. Clients can send messages to social workers at any hour of the day or night and receive a response within hours. 

It is also important to note that, for some clients, especially those without comprehensive insurance coverage for mental health services, distance and remote counseling may be much less expensive than face-to-face counseling. Social workers' fees may be lower because they do not have to help cover the overhead typically associated with office-based services.

The Ethical Issues
Contemporary social workers are wrestling with the ways in which all manner of digital technology is working its way into their professional lives.  Today's social workers are sorting out the ways in which social media and social networking (eg, Facebook, Twitter, and LinkedIn), text messages, video, e-mail, avatar, and telephone counseling have a place in the delivery of clinical services. Whether you are a social worker who is an enthusiastic proponent of incorporating digital and other electronic technology into your professional repertoire, or a fervent critic, the reality is that some forms of this technology are here to stay. 

Given this reality, it behooves us to think hard about the looming ethical issues, some of which involve age-old questions that are taking on new forms (a variant, perhaps, of the saying about old wine in new bottles). For example, what does it mean to obtain truly informed consent from clients whom social workers may never meet in person? How does a social worker ensure that these clients understand the potential benefits and risks associated with such remote services? How can social workers ensure that they know the identity of clients they never meet in person, and that these clients are old enough and competent enough to consent to services?

What steps do social workers need to take to protect clients' privacy and confidentiality? How do social workers document clinically relevant text messages, Facebook postings, and e-mail communications? Social workers need to be acquainted with state-of-the-art encryption software and technology, and ensure that clients fully understand their role in protecting private and confidential information communicated via digital technology. 

Digital technology has an important role in the delivery of social work services. This technology can expand social work's reach and enhance the ability of people to obtain help. That said, the rapid proliferation of a wide range of digital and other electronic tools—including the possibility of providing so-called therapy via text messaging—has raised unprecedented ethical challenges and a nearly endless list of questions. Clearly, there are tradeoffs when social workers use digital and other electronic technology to serve clients. Social workers must think about these tradeoffs and their ethical implications very, very carefully.